Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 Nothing to disclose. Disclosures Ivan J Chavez MD Case ECG History 60 y/o male No prior history of CAD In car at casino complaining of chest pain Depression, Smoker FH: Father PE, mother renal transplant, brother hyperlipidemia Exam Pale, diaphoretic, confused SBP=100, cool extremities Case ED course Progressively obtunded Level 1 activated Ticagrelor 180mg, heparin 4000U, ASA Multiple episodes of ventricular tachycardia Multiple defibrillation, CPR Progressive shock, Intubated External cooling, Lucas, transfer to ANW Labs: ph: 6.8 po2: 54 pco2: 58.5 bicarbonate: 9.8, lactate 10.5 Case Summary Acute STEMI VT/VF arrest Cardiogenic shock Recurrent cardiac arrest and refractory shock LUCAS dependent upon arrival (110 minutes)
Next Steps Is this patient dead? Basic Life Support (BLS) Advanced Cardiopulmonary Life Support (ACLS) Next Steps ECPR Is this patient dead? Basic Life Support (BLS) Advanced Cardiopulmonary Life Support (ACLS) ECMO Cardiopulmonary Life Support (ECLS) Definition Purpose Evidence Indications Methods Outcomes ECPR Definition The utilization of extra-corporeal membrane oxygenation via femoral venous and arterial access to provide artificial cardiopulmonary circulation as an alternative to traditional ventilation and external cardiac massage ECPR Purpose Improve Outcomes Extension Beyond BLS and ACLS for refractory cardiac arrest Reversal Management of post resuscitation syndrome Bridge Interventional therapies to allow management of potential reversible conditions
ECPR Purpose Improving Cardiac Arrest Outcomes 1950 s mortality 50% Stephenson HE Jr. Ann Surg. 1953; 137: 731 744 1966 original consensus statement on CPR National Academy of Sciences National Research Council Ad Hoc Committee on Cardiopulmonary Resuscitation. Cardiopulmonary resuscitation. JAMA. 1966; 198: 372 379 Currently overall prognosis after ROSC has only minimally improved ECPR Purpose Research focused on improving the rate of ROSC Post Resuscitation Syndrome Brain injury Myocardial Dysfunction/Cardiogenic Shock Systemic Ischemia/Reperfusion Response Persistent Precipitating Pathology Systemic Ischemia/Reperfusion Response Most severe state of cardiogenic shock Abrupt cessation of oxygen and nutrient delivery Increased oxygen debt Endothelial activation and inflammatory response Multisystem organ failure Whole body ischemia/reperfusion Activation of immunological and coagulation pathways Multisystem organ failure Myocardial Dysfunction/Cardiogenic Shock Judith S. Hochman Circulation. 2003;107:2998-3002 Copyright American Heart Association, Inc. All rights reserved. ECPR Purpose Potential role for ECMO Extend resuscitation when ROSC cannot be achieved Reverse the consequences of post resuscitation syndrome Increase likelihood of achieving ROSB Allow evaluation and intervention on underlying etiology of cardiac arrest No prospective randomized clinical trials ESLO ECLS Registry Several small observational studies
Resuscitation 2015 92, 70-76DOI: (10.1016/j.resuscitation.2015.04.016) Copyright 2015 The Authors Terms and Conditions SAVE-J The Lancet 2008 372, 554-561DOI: (10.1016/S0140-6736(08)60958-7) Prospective observational study OHCA Cardiac arrest VT/VF Arrival within 45 minutes 454 patients (260 ECPR, 194 CPR) Favorable neurological outcomes (CPC 1-2) ITT One month 12.3% ECPR and 1.5% CPR (p<0.0001) Six month 11.2% ECPR and 2.6% CPR (p,0.001) CHEER Trial Prospective study Age 18-65 years Cardiac arrest of cardiac origin Initial rhythm VF CPR>30min 26 patients, 11 OHCA, 15 IHCA Mechanical chest compression Hypothermia EMS activated, ED ECMO Wean from ECMO 54% Hospital discharge 54% CPC 1 survivors 100%
42 patients in cardiac arrest 18 patients met protocol criteria of ECPR 8 resuscitated on ECMO/ECPR 5 discharged neurologically intact (61%) Similar indications as for BLS/ACLS Patient generally healthy prior to cardiac arrest Goals of therapy are curative Cause of cardiac arrest treatable When traditional BLS/ACLS strategies have failed Extension of traditional BLS/ACLS In hospital vs out of hospital ANW in hospital ECPR protocol Age 18-75 Arrest of cardiac origin (VT/VF) ETCO2>20 Patient on HH4000/5000/5200 or CVICU ECPR candidacy determined at 10 minutes LEVEL 1 ECMO called and patient transferred to cath lab on LUCAS ECMO initiation within 60 minutes of arrest ANW out of hospital ECPR protocol Age 18-75 Witnessed arrest of cardiac origin (VT/VF) No flow of less 5 minutes ETCO2>10 Consistent MAP during transport (MAP 45mmHg or SBP 70mmHg) LEVEL-1 ECMO activation of the Cath lab ECMO initiation within 60 minutes of arrest
ECPR Method Vascular Ultrasound J Am Coll Cardiol Intv. 2010;3(7):751-758. doi:10.1016/j.jcin.2010.04.015 ECMO Cannulation Cannulas Retrograde Arterial Cannula 17-19Fr Venous Cannula 19-21Fr Anterograde Limb Perfusion 6-8Fr ECPR: Method J.M. Bellezzo et al. / Resuscitation 83 (2012) 966 970
ECPR: Methods ECPR Paradigm Shift CARDIAC CARDIAC ARREST ROSC ARREST Post Resuscitation Post Resuscitation Syndrome Syndrome BLS/ACLS Hemodynamic ECLS/ECPR, Support, PCI, PCI, Hypothermia IABP, PCI, Hypothermia J.M. Bellezzo et al. / Resuscitation 83 (2012) 966 970 Improve Survival
Summary Improving survival following cardiac arrest continues to be challenging ECPR can provide an extension to traditional ACLS for refractory cardiac arrest ECPR facilitates the management of post resuscitation syndrome and it s consequences ECPR facilitates ROSC/ROSB ECPR improve both short term and long term outcomes compared to conventional CPR Summary ECPR is associated with improved neurological outcomes compared conventional CPR Shortening time of CPR with ECPR (<35 min) is associated with better outcomes Cannulation can be challenging ECPR provides a bridge to definitive therapy ECPR indications are similar to those for BLS/ACLS Patient selection important It just so happens that your friend here is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive! -Billy Crystal as Miracle Max The Princess Bride 1987 Case